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Client Intake Form awake

    Client Intake Form

    Include name, phone number, email and your relationship to this person.

    Session Details

    Healthcare Facility Admissions

    Please list all surgeries including dates.

    Including detox, rehab and all other drug/alcohol treatment programs.

    Including mental health hospitalizations and any other type of wellness program.

    Physical Health History

    Please select all that apply. If the condition is not listed, select 'other' to add it. If nothing
    applies, please select 'none'. Do you suffer from, or have ever been diagnosed with, any of
    the following

    Mental Health History

    If you are currently suicidal, please go to the nearest hospital or crisis center or contact your
    country's suicide hotline immediately.

    If you are currently under the care of a mental healthcare professional, please describe.
    Otherwise, leave blank.

    Drugs, Medications & Herbs

    Are you currently using any of the following drugs on a regular basis?

    Are you currently taking methadone or suboxone?

    Have you ever taken Methadone or Suboxone in the past?

    Are you currently using any of the following opioids?

    Are you currently taking any of the following benzodiazepines?

    Are you currently taking any of the following antidepressant medications?

    Are you currently taking any of the following mood-stabilizing medications?

    Are you currently taking any of the following ADD/ADHD medication?

    Do you currently smoke marijuana on a regular basis?

    Do you have experience with any of the following plant medicines, psychedelics or
    psychoactive drugs?

    Please list all other medications and supplements you are taking (including vitamins, herbs,
    inhalers, birth control pill, etc.) with dosage, frequency and reason for taking.

    Health Habits

    Mild exercise

    How many meals do you eat a day?

    What is your diet like?

    Are you on a diet? If yes, is it a physician prescribed medical diet? Please describe.

    Please list any dietary restrictions you have.

    Please list any allergies you have.

    What is your average daily salt intake?

    What is your average daily sugar intake?

    Do you drink any Caffeine?

    What is the name of caffeine drink?

    How many cups per day?

    Do you drink alcohol?

    What kind? How many drinks per week?

    Are you physically addicted to alcohol?

    Have you considered stopping drinking?

    Have you ever experienced blackouts while drinking?

    Are you prone to binge drinking?

    Do you suffer from DTs or shaking if you stop drinking?

    Do you use tobacco?

    Personal History

    What are your personal beliefs and practices, if any?

    What were your and/or your family's spiritual beliefs and practices growing up, if any?

    How do you view yourself and others?

    How would you describe your childhood and early family life?

    Would you say you had a traumatic childhood?

    Have you ever been sexually assaulted or abused?

    What is your current home life like? Who do you live with? Are the people you live with clean,
    sober and supportive?

    What is your occupation?

    Please describe a typical day in your life.

    How would you describe your sleep patterns? Do you have difficulty getting to sleep or
    staying asleep? Do you feel restless? How many hours of sleep do you get on average/night?

    How do you usually handle emotional events and experiences?

    What great disappointments have you experienced in your life?

    What great joys?*

    What do you take pride in? What do you like doing? (If you are coming to us for addiction
    treatment - what do/did you enjoy doing when you are not/before you started, using?)

    If you are coming to us for addiction treatment, have you gotten clean in the past? For how
    long and how did you do it?

    Do you have any particular requirements post session that need to be addressed?

    Are you willing to be without electronic devices for the duration of your treatment? (Family
    members may reach AWAKE staff at anytime throughout the retreat).

    Are you willing to experience sleeplessness (depending on which medicine session you
    partake in) should it arise?

    Are you ready for a change in your life?

    Is there any other information we should know about you?